We used to be among the nation’s healthiest states. But we’ve been plummeting toward the bottom half of the pack.

The United Health Foundation, which has been ranking the overall health of states since 1990, recently named Kansas and Missouri among the seven states that have sunk the furthest on its list over the past 25 years. The rankings are based on a broad range of health, environmental and socioeconomic data.

A robust Kansas was in 12th place in 1990; now it’s a middling 27th, according to the latest edition of the foundation’s America’s Health Rankings. Missouri used to be among the better half of states at 24th place; now it’s a dismal 36th.

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Sure, plenty of us still smoke. Few of us exercise. We’re not bothering to keep our kids up to date on their vaccinations. And we aren’t eating our fruits and vegetables.

But there’s a lot more going on here, health experts say. In much of the Midwest, we just haven’t been making a major public commitment to improving the health of our citizens, they say, and the results are catching up with us.

Along with Kansas and Missouri, the five other states that have fallen the most in the health rankings are all in the nation’s heartland, from Ohio to Oklahoma. It’s not that these states haven’t made any improvements; some trends are positive.

And there are visible signs of progress, like bicycle lanes cropping up in Kansas City, Kan.; community gardens in Jackson County; and new smoking restrictions in many places.

But other states, notably on the East and West coasts, have been doing a lot more.

“What explains this dramatic difference between the coasts and the Midwest is broad investments on the coasts in things that make communities healthy, from education to public health,” said Patrick Remington, associate dean for public health at the University of Wisconsin. Wisconsin dropped from seventh to 23rd.

“It generally reflects an attitude in these Midwestern states that there should be a limited role for public health, as compared to a place like New York,” Remington said.

New York saw the most dramatic improvement in the rankings over the past 25 years, rising from 40th place to 14th. New York expanded its Medicaid program to provide health insurance coverage for more people with low incomes long before the Affordable Care Act made that a national policy — although it’s a policy that Kansas, Missouri and many other states have not followed.

New York also has strict laws limiting public smoking. New York City even tried to prohibit megaservings of sugary drinks before a court struck down the ban.

“Obviously, Missouri is a different place from New York, and that’s fine,” said Sarah Patrick, an associate professor at the St. Louis University College for Public Health and Social Justice. “But we are getting behind the curve on these health behaviors.”

Patrick used to be Missouri’s state epidemiologist, tracking its disease trends from 2008 through 2011. She saw the state’s approach to health promotion firsthand.

“Missouri has just been (reluctant) to take policy actions to improve health,” she said. “There’s a lack of engagement or belief that policies can work.”

Missouri slumps

Consider the data cited by America’s Health Rankings:

▪ Over the past 25 years, the nation’s cancer death rate has been slowly going down. Missouri’s has been creeping up.

▪ In 1990, the rate of heart disease deaths was lower in Missouri than for the nation as a whole. Now the rate is higher.

▪ Diabetes used to be slightly less prevalent in Missouri than in the rest of the nation. Now it’s just as common.

Out of the 27 measures used in the rankings, Missouri is among the bottom 20 states in 18 categories. In four categories —including smoking and immunizing adolescents — it’s among the 10 worst.

Patrick said some relatively simple policy changes, starting with raising the state’s tobacco tax, could benefit the health of Missourians.

At 17 cents per pack of cigarettes, Missouri has the lowest tobacco tax in the nation. The average state tax is $1.54 per pack. New York’s tax is the highest at $4.35 per pack.

“We’re just ignoring some of the evidence out there that higher taxes discourage smoking,” Patrick said.

Missouri also can do more to prevent drug deaths, she said. It’s the only state in the nation that doesn’t have a system for monitoring sales of prescription painkillers and other potentially dangerous drugs, she said.

The drug death rate has been increasing in Missouri during the past few years while it has remained fairly flat nationwide.

A factor that stands out for Patrick is funding for public health.

“Since the beginning of the rankings, Missouri has been near the bottom,” she said. “Many times, county health departments feel that public health functions are being pushed over to them by the state.”

According to the Trust for America’s Health, Missouri budgets less money per capita for public health than any other state. The national median for state spending is $27.49 per person. In Missouri, it’s $5.86.

For the Kansas City Health Department, that means the state covers only about a fifth of what it costs to manage outbreaks of infectious diseases such as measles and whooping cough, department director Rex Archer said.

Archer estimates that his department’s budget would grow by more than $10 million if Missouri spent as much on public health as other states do.

“I could make a huge difference in life expectancies in Kansas City if I had just the median of what other health departments are paid,” he said.

With more money, Archer said, he could more aggressively tackle childhood exposure to lead, broaden outreach efforts to get more people immunized against the flu and provide more new parents with advice on good nutrition and language learning to better the brain development of their young children.

Archer suggested that it may have been easier politically to scrimp on public health than on other government programs. Budget cuts for roads or schools quickly lead to potholes and crowded classrooms. Health programs are less visible and can take years to yield a payoff.

Missouri’s tight budget for public health “didn’t happen on any one person’s watch,” Archer said. “But collectively, we just let it go downhill.”

In an emailed response, the Missouri Department of Health and Senior Services said that in recent years it has supported efforts to expand Medicaid and implement a prescription drug monitoring program. The department is “continuously looking for potential initiatives and resources that could help improve health and wellness in our state … (and) is always working to ensure both state and federal resources are used as effectively as possible.”

But Missouri lawmakers have balked at expanding Medicaid or starting a prescription drug monitoring program.

Kansas too

Public health funding in Kansas also has come up short, and that’s helped send the state skidding in the health rankings, said Jeff Willett, vice president of the Wichita-based Kansas Health Foundation, which funds health improvement initiatives.

The state budget’s $14.07 per capita for public health puts it in 44th place, according to the Trust for America’s Health.

And while it’s not in therankings cellar like Missouri, Kansas has slipped badly:

▪ Kansas has seen its cancer death rate rise since 1990. Nationally it has fallen.

▪ Kansas has one of the highest rates of occupational fatalities, more than 50 percent higher than the national rate.

▪ Kansas has among the lowest rates for immunizing children and adolescents. Just 53.8 percent of Kansas teens had all their recommended shots. In neighboring Nebraska, 68.4 percent of teens were fully immunized.

“These are the consequences of more than two decades of underinvestment in public health,” Willett said.

And even where Kansas has made strides, such as reducing smoking, “the rest of the nation is outpacing us,” he said. Kansas is among the 20 states with the highest smoking rates, according to the health rankings.

“We believe the state could turn this around,” Willett said.

Increasing the state’s tobacco tax — at 79 cents per pack, among the lowest — would raise revenues and reduce smoking, he said.

The Kansas Department of Health and Environment said in an emailed statement to The Star that since 2011 the department “has taken a closer look at our core public health mission and (has) implemented a strategic approach to budgeting for programs across the agency to better align our spending with our core public health mission … to protect and improve the health and environment of all Kansans.”

But casting a giant shadow over spending on public health is the state’s looming revenue shortfall. Gov. Sam Brownback’s recently proposed budget includes cuts to the state health department.

Turning it around

America’s Health Rankings is the longest-running effort to compare the health status of states by using the voluminous data collected by government agencies, medical associations, academics and private organizations.

The rankings are determined by the United Health Foundation in partnership with the American Public Health Association and the Partnership for Prevention, a nonprofit organization that promotes preventive health care services.

The measures that go into the rankings include a range of health behaviors like smoking and binge drinking; personal health indicators such as diabetes and obesity; and indicators, such as preventable hospitalizations, that are used to rank health care quality. Also in the mix are environmental and social factors such as air pollution levels and number of violent crimes.

Over the past quarter century, the rankingshave tracked numerous improvements in measures of the nation’s health: Fewer people smoke. More are graduating from high school. Deaths from cancer and heart disease are down. There’s less air pollution and fewer violent crimes.

But at the same time, rates of obesity and diabetes have soared. And levels of physical inactivity have remained persistently high.

States that have made the most progress “looked at their numbers and made deliberate efforts to focus on their weaknesses,” said Georges Benjamin, executive director of the American Public Health Association.

Benjamin was Maryland’s secretary of health from 1999 to 2002. His state was among the six to rise the most in the rankings, from 31st in 1990 to 16th in 2014.

Maryland “focused like a laser” on reducing its high infant mortality rate, Benjamin said, developing initiatives to make sure that pregnant women received health care and substance abuse treatment when needed.

Although still slightly above the national rate, infant mortality in Maryland dropped 43 percent over the past 25 years.

When many other states were plugging holes in their budget with the windfall they received from the multibillion-dollar 1998 national settlement of lawsuits against tobacco companies, Maryland was devoting much of it to cancer care and smoking prevention, Benjamin said. The state now has one of the lowest smoking rates in the nation.

“Public policy has always been a part of public health,” Benjamin said. “In Maryland, we strongly believe that public policy, when done right, does work.”

KC area efforts

Those kinds of initiatives have started taking root locally.

Since 2008, Truman Medical Centers has run a weekly produce market at its Hospital Hill and Lakewood campuses. A few years ago, the hospital ripped the seats out of an old city bus and replaced them with bins to create a rolling produce stand that brings fresh fruit and vegetables to underserved neighborhoods.

The hospital’s next step is to build a grocery store on land it has acquired at 27th Street and Troost Avenue.

“The idea is to bring better choices of food to the people in those areas,” hospital spokesman Shane Kovac said.

Kansas City, Kan., was galvanized into action in 2009 after a county-by-county health ranking placed Wyandotte County dead last in the state.

The mayor at the time, Joe Reardon, summoned community leaders to come up with priorities for improving the city’s health and assembled teams of volunteers to develop plans. Their goals included making health care more affordable, fresh food more accessible, and streets and sidewalks friendlier to pedestrians and cyclists.

“We have an incredibly supportive commission and mayor, but we needed people like these in the community advocating,” said Wesley McKain, program coordinator of the Healthy Communities Wyandotte initiative, which came out of these early discussions.

The results are beginning to appear. About a year ago, Wyandotte County built its first bike lane. The 31/2-mile stretch along Southwest Boulevard is being extended along Merriam Lane to connect with Johnson County. Another bike lane is being developed along 10th Street.

During the enrollment periods for health insurance plans through the Affordable Care Act, Wyandotte County government and community groups mobilized to sign up the uninsured. Banks of volunteers were stationed at the health department and other locations to help people enroll. By last spring, the uninsured rate in Wyandotte County had fallen from 26 percent to 18 percent.

The Unified Government Commission last month approved a master plan, spearheaded by Mayor Mark Holland, to redevelop downtown Kansas City, Kan., as a “healthy campus” with a community and recreation center, grocery store, farmers market, green space, recreation fields, trails and sidewalks. Fundraising for the community center is underway.

“I do have faith that change is possible,” Patrick said. “The idea is, how do we roll up our sleeves and deal with these issues?”

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